It seems that there are two major factors important for making this happen in a hospital setting:
1) The hospital staff must have a strong commitment to active, upright labor.
2) The staff must also have first-hand experience facilitating this, especially for moms who have epidurals, IVs, fetal monitors, etc.
Okay, enough of me. Here's doctorjen:
I find that with some help it is possible to get almost all epidural moms upright. Most have enough sensation to support themselves on hands and knees. We put the back of the bed up most of the way so mom can drape her upper body over the top of the bed and then help them get their knees securely under them, and it usually works. They may need assistance to get in this position, but they usually can sustain once we get them up. Also, squatting is not too hard. My labor bed goes into a full chair position with the feet dropped all the way down. We then put the squat bar on the bottom of the bed. Mom can sit at the edge of the top of the bed between contractions and with help when a contraction starts and leaning on the squat bar, they can drop down into a squat to push. Some epidural moms have enough sensation to get themselves up and down and if not, they can use their arms for support and we just help them get up and down. Again, once they are in the squat they usually have enough sensation to support themselves. I have a policy of no operative vaginal delivery without trying a full squat first, and it almost always works. And very importantly, I try to let all epidural moms labor down as much as possible and not do any pushing until they have some urge and sensation. If we get to 2 hours of complete dilation with no sensation yet, we negotiate about turning it off and then most moms eventually get an urge to push.
I find it much harder to move a mom with an epidural around, and they don't tend to be changing positions frequently like a mom laboring spontaneously without anesthesia, but it's both possible to do it and helpful. My nurses were way skeptical at first, but after seeing a few babies come sailing out quickly in a squat they are all big believers now and will be telling me to get mama up if I haven't for some reason thought of it! The hardest part is moving all the wires we have going with an epidural --external fetal monitor, external contraction monitor, urinary catheter, IV, epidural line, and blood pressure cuff. We have it down to a science now, though--we unplug everything that unplugs, pull all wires to one side, flip or move the mama, and replug everything in, passing them under the mama's belly if we've moved to hands and knees. I enforce with my labor clients and my nurses that the mama's comfort is our number one concern and the monitors are our job to keep track of. So mama moves as she needs to, and we chase the cords....
Thought you might like to hear about a nice upright birth I attended an hour and a half ago. Second baby, spontaneous labor at 40 weeks 4 days, no augmentation, no IV, no AROM, just labor. Mama did a lot of laboring in bed because she was tired, but at the very end of labor, she got up. She had been grunting a bit with contractions, but not really pushing, and she thought she needed to pee. We went to the bathroom, but she wasn't able to get comfortable and wasn't able to go. She hopped up and down from the toilet several times, and then squatted on the floor holding on to the sink for a bit. Finally, she said "forget it" and we headed back into the labor room. At this point, she stopped at the end of the bed and squatted down on the floor holding on to the end of the bed. This felt good to her, so we spread some pads on the floor, and over the next few contractions she would go from kneeling to squatting, to kneeling on one knee, to hands and knees. Suddenly, her water broke with a huge gush. Then she decided to try the bathroom again and we went back in the bathroom, but again, a lot of up and down but not able to go. She decided to head back into the labor room, but then she knelt back down on the floor in the door of the bathroom suddenly and pushed all out with a contraction, and gave me that wide eyed "baby's coming" look. I asked her if she was comfortable there in the doorway, and she didn't answer but got up and headed back towards her pile of bed pads on the floor and knelt back down. Over the next 3 contractions she knelt, squatted, leaned back on her hands and feet (like a crab walk position almost!) and then back to squatting, sometimes holding the edge of the bed for support with both hands, sometimes with one hand, sometimes with her hands on the floor.
Finally, she pushed out the baby's head in a squat but almost sitting over one leg, so that leg was flexed and the other one a little extended, and then for baby's big, tight-fitting shoulders, she first knelt, then leaned back on her hands and lifted her hips in the air and the little linebacker finally slid out. The dad then sat down on the floor behind the mom and we slid a dry bit of pad under her and she sat down on the floor, leaned back into her partner's lap, and snuggled her baby on her tummy. The thing that always impresses me about a spontaneous second stage in an upright mother is that it's not a matter of getting in one position and pushing the baby out, but most mamas move frequently including during contractions. In the 3 long pushing contractions she had, she probably changed position 15 times--and with that baby's kind of sticky shoulders, I'm glad she was freely mobile and able to wiggle all over and push him out! That, in my experience, is what a true upright birth looks like! Most docs, though, would be driven nuts by having the baby be such a moving target (of course he was never more than a couple inches from the floor and could have easily just slid onto the pads on the floor) and having to get on the floor themselves. Luckily, I'm young and healthy and can kneel or squat myself pretty well, and fortunately tonight I didn't have one of the 2 currently 3rd trimester pregnant nurses trying to get down there with me.
Anyway, that's what an upright birth can look like in the hospital - even with a doctor.